<h:html xmlns:h="http://www.w3.org/1999/xhtml"
        xmlns="http://www.w3.org/2002/xforms"
	  xmlns:ev="http://www.w3.org/2001/xml-events"
	  xmlns:xsd="http://www.w3.org/2001/XMLSchema"
	  xmlns:jr="http://openrosa.org/javarosa">
<h:head>
    <h:title>HMIS 033a: Health Unit Notifiable Disease Report</h:title>
    <meta jr:name="hmis033aeng"/>
    <model>
	<instance>
		<HMISFormA xmlns="http://gatherdata.org/en_UG/hmis033a">
			<Meta>
				<DeviceID />
				<TimeStart />
				<TimeEnd />
			</Meta>
		
			<DateOfReport/>
			<ReportNumberThisYear/>
			<FinancialYear/>
			<HealthUnit/>
			<HealthUnitCode/>
			<SubCounty/>
			<District/>
			<DiseaseDiagnosis/>

			<Patients>
				<Patient1>
					<PatientNumber/>
					<Name/>
					<Sex/>
					<Age/>
					<Village/>
					<Parish/>
					<Symptoms/>
					<DateOfOnset/>
					<Confirmed/>
					<Lab/>
					<Immunisation/>
					<Status/>
				</Patient1>
				<Patient2>
					<PatientNumber/>
					<Name/>
					<Sex/>
					<Age/>
					<Village/>
					<Parish/>
					<Symptoms/>
					<DateOfOnset/>
					<Confirmed/>
					<Lab/>
					<Immunisation/>
					<Status/>
				</Patient2>
				<Patient3>
					<PatientNumber/>
					<Name/>
					<Sex/>
					<Age/>
					<Village/>
					<Parish/>
					<Symptoms/>
					<DateOfOnset/>
					<Confirmed/>
					<Lab/>
					<Immunisation/>
					<Status/>
				</Patient3>
				<Patient4>
					<PatientNumber/>
					<Name/>
					<Sex/>
					<Age/>
					<Village/>
					<Parish/>
					<Symptoms/>
					<DateOfOnset/>
					<Confirmed/>
					<Lab/>
					<Immunisation/>
					<Status/>
				</Patient4>
				<Patient5>
					<PatientNumber/>
					<Name/>
					<Sex/>
					<Age/>
					<Village/>
					<Parish/>
					<Symptoms/>
					<DateOfOnset/>
					<Confirmed/>
					<Lab/>
					<Immunisation/>
					<Status/>
				</Patient5>
				<Patient6>
					<PatientNumber/>
					<Name/>
					<Sex/>
					<Age/>
					<Village/>
					<Parish/>
					<Symptoms/>
					<DateOfOnset/>
					<Confirmed/>
					<Lab/>
					<Immunisation/>
					<Status/>
				</Patient6>
			</Patients>

			<ActionsTakenByHealthUnit/>
			<Remarks/>
			<NameOfInCharge/>

			<internal>
				<more1/><more2/><more3/><more4/><more5/>
			</internal>
		</HMISFormA>
	</instance>

	<bind id="hidden1" nodeset="/HMISFormA/Meta/DeviceID" type="xsd:string" jr:preload="property" jr:preloadParams="DeviceID" />
	<bind id="hidden2" nodeset="/HMISFormA/Meta/TimeStart" type="xsd:dateTime" jr:preload="timestamp" jr:preloadParams="start" />
	<bind id="hidden3" nodeset="/HMISFormA/Meta/TimeEnd" type="xsd:dateTime" jr:preload="timestamp" jr:preloadParams="end" />

	<bind id="prop1" nodeset="/HMISFormA/HealthUnit" type="xsd:string" jr:preload="property" jr:preloadParams="health-unit" />
	<bind id="prop2" nodeset="/HMISFormA/HealthUnitCode" type="xsd:string" jr:preload="property" jr:preloadParams="health-unit-code" />
	<bind id="prop3" nodeset="/HMISFormA/SubCounty" type="xsd:string" jr:preload="property" jr:preloadParams="sub-county" />
	<bind id="prop4" nodeset="/HMISFormA/District" type="xsd:string" jr:preload="property" jr:preloadParams="district" />
		
	<bind id="a" nodeset="/HMISFormA/DateOfReport" type="xsd:date" jr:preload="date" jr:preloadParams="today" />
	<bind id="b" nodeset="/HMISFormA/ReportNumberThisYear" type="xsd:int" required="true()"/>
	<bind id="c" nodeset="/HMISFormA/FinancialYear" type="xsd:int" jr:preload="property" jr:preloadParams="fin-year" />
	<bind id="p1a" nodeset="/HMISFormA/Patients/Patient1/PatientNumber" type="xsd:int"/>
	<bind id="p1b" nodeset="/HMISFormA/Patients/Patient1/Age" type="xsd:int"/>
	<bind id="p1c" nodeset="/HMISFormA/Patients/Patient1/DateOfOnset" type="xsd:date"/>
	<bind id="p2a" nodeset="/HMISFormA/Patients/Patient2/PatientNumber" type="xsd:int"/>
	<bind id="p2b" nodeset="/HMISFormA/Patients/Patient2/Age" type="xsd:int"/>
	<bind id="p2c" nodeset="/HMISFormA/Patients/Patient2/DateOfOnset" type="xsd:date"/>
	<bind id="p3a" nodeset="/HMISFormA/Patients/Patient3/PatientNumber" type="xsd:int"/>
	<bind id="p3b" nodeset="/HMISFormA/Patients/Patient3/Age" type="xsd:int"/>
	<bind id="p3c" nodeset="/HMISFormA/Patients/Patient3/DateOfOnset" type="xsd:date"/>
	<bind id="p4a" nodeset="/HMISFormA/Patients/Patient4/PatientNumber" type="xsd:int"/>
	<bind id="p4b" nodeset="/HMISFormA/Patients/Patient4/Age" type="xsd:int"/>
	<bind id="p4c" nodeset="/HMISFormA/Patients/Patient4/DateOfOnset" type="xsd:date"/>
	<bind id="p5a" nodeset="/HMISFormA/Patients/Patient5/PatientNumber" type="xsd:int"/>
	<bind id="p5b" nodeset="/HMISFormA/Patients/Patient5/Age" type="xsd:int"/>
	<bind id="p5c" nodeset="/HMISFormA/Patients/Patient5/DateOfOnset" type="xsd:date"/>
	<bind id="p6a" nodeset="/HMISFormA/Patients/Patient6/PatientNumber" type="xsd:int"/>
	<bind id="p6b" nodeset="/HMISFormA/Patients/Patient6/Age" type="xsd:int"/>
	<bind id="p6c" nodeset="/HMISFormA/Patients/Patient6/DateOfOnset" type="xsd:date"/>
    </model>
</h:head>			
<h:body>

        <input bind="a">
            <label>Date of Report</label>
        </input>
        <input bind="b">
            <label>Report number this year</label>
        </input>
        <input bind="c">
            <label>Financial Year</label>
        </input>
	
        <input bind="prop1">
            <label>Health Unit</label>
        </input>
        <input bind="prop2">
            <label>Health Unit Code</label>
        </input>
        <input bind="prop3">
            <label>Sub county</label>
        </input>
        <input bind="prop4">
            <label>District</label>
        </input>

 	<select1 ref="/HMISFormA/DiseaseDiagnosis">
		<label>Disease diagnosis</label>
		<item><label>Acute Flaccid Paralysis</label><value>Acute Flaccid Paralysis</value></item>
		<item><label>Animal Bites</label><value>Animal Bites</value></item>
		<item><label>Dysentery</label><value>Dysentery</value></item>
		<item><label>Malaria</label><value>Malaria</value></item>
		<item><label>Meningitis</label><value>Meningitis</value></item>
		<item><label>more...</label><value>more...</value></item>
	</select1>

	<select1 ref="/HMISFormA/DiseaseDiagnosis" relevant="/HMISFormA/DiseaseDiagnosis='more...'">
		<label>Disease diagnosis (cont'd)</label>
		<item><label>Rabies</label><value>Rabies</value></item>
		<item><label>Cholera</label><value>Cholera</value></item>
		<item><label>Guinea Worm</label><value>Guinea Worm</value></item>
		<item><label>Measles</label><value>Measles</value></item>
		<item><label>Neonatal Tetanus</label><value>Neonatal Tetanus</value></item>
		<item><label>Plague</label><value>Plague</value></item>
		<item><label>Yellow Fever</label><value>Yellow Fever</value></item>
		<item><label>Other Viral Heamorrhagic Fevers</label><value>Other Viral Heamorrhagic Fevers</value></item>
		<item><label>Other Emerging Infectious Diseases</label><value>Other Emerging Infectious Diseases</value></item>
		<item><label>Other</label><value>Other</value></item>
	</select1>

		<input bind="p1a"><label>Patient 1: Patient #</label></input>
		<input ref="/HMISFormA/Patients/Patient1/Name"><label>Patient 1: Name</label></input>
		<select1 ref="/HMISFormA/Patients/Patient1/Sex"><label>Patient 1: Sex</label>
			<item><label>Male</label><value>m</value></item>
			<item><label>Female</label><value>f</value></item>
		</select1>
		<input bind="p1b"><label>Patient 1: Age</label></input>
		<input ref="/HMISFormA/Patients/Patient1/Village"><label>Patient 1: Village</label></input>
		<input ref="/HMISFormA/Patients/Patient1/Parish"><label>Patient 1: Parish</label></input>
		<input ref="/HMISFormA/Patients/Patient1/Symptoms"><label>Patient 1: Symptoms and Signs</label></input>
		<input bind="p1c"><label>Patient 1: Date of Onset</label></input>
		<select1 ref="/HMISFormA/Patients/Patient1/Confirmed"><label>Patient 1: Clinically Confirmed?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 ref="/HMISFormA/Patients/Patient1/Lab"><label>Patient 1: Lab Results Used in Diagnosis?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 ref="/HMISFormA/Patients/Patient1/Immunisation"><label>Patient 1: Immunised?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
			<item><label>Unknown</label><value>u</value></item>
		</select1>
		<input ref="/HMISFormA/Patients/Patient1/Status"><label>Patient 1: Status</label></input>

		<select1 ref="/HMISFormA/internal/more1"><label>More patients?</label>
		<item><label>Yes</label><value>yes</value></item>
		<item><label>No</label><value>no</value></item>
		</select1>



		
		<input relevant="/HMISFormA/internal/more1='yes'" bind="p2a"><label>Patient 2: Patient #</label></input>
		<input relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Name"><label>Patient 2: Name</label></input>
		<select1 relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Sex"><label>Patient 2: Sex</label>
			<item><label>Male</label><value>m</value></item>
			<item><label>Female</label><value>f</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more1='yes'" bind="p2b"><label>Patient 2: Age</label></input>
		<input relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Village"><label>Patient 2: Village</label></input>
		<input relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Parish"><label>Patient 2: Parish</label></input>
		<input relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Symptoms"><label>Patient 2: Symptoms and Signs</label></input>
		<input relevant="/HMISFormA/internal/more1='yes'" bind="p2c"><label>Patient 2: Date of Onset</label></input>
		<select1 relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Confirmed"><label>Patient 2: Clinically Confirmed?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Lab"><label>Patient 2: Lab Results Used in Diagnosis?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Immunisation"><label>Patient 2: Immunised?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
			<item><label>Unknown</label><value>u</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/Patients/Patient2/Status"><label>Patient 2: Status</label></input>

		<select1 relevant="/HMISFormA/internal/more1='yes'" ref="/HMISFormA/internal/more2"><label>More patients?</label>
		<item><label>Yes</label><value>yes</value></item>
		<item><label>No</label><value>no</value></item>
		</select1>





		<input relevant="/HMISFormA/internal/more2='yes'" bind="p3a"><label>Patient 3: Patient #</label></input>
		<input relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Name"><label>Patient 3: Name</label></input>
		<select1 relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Sex"><label>Patient 3: Sex</label>
			<item><label>Male</label><value>m</value></item>
			<item><label>Female</label><value>f</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more2='yes'" bind="p3b"><label>Patient 3: Age</label></input>
		<input relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Village"><label>Patient 3: Village</label></input>
		<input relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Parish"><label>Patient 3: Parish</label></input>
		<input relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Symptoms"><label>Patient 3: Symptoms and Signs</label></input>
		<input relevant="/HMISFormA/internal/more2='yes'" bind="p3c"><label>Patient 3: Date of Onset</label></input>
		<select1 relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Confirmed"><label>Patient 3: Clinically Confirmed?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Lab"><label>Patient 3: Lab Results Used in Diagnosis?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Immunisation"><label>Patient 3: Immunised?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
			<item><label>Unknown</label><value>u</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/Patients/Patient3/Status"><label>Patient 3: Status</label></input>

		<select1 relevant="/HMISFormA/internal/more2='yes'" ref="/HMISFormA/internal/more3"><label>More patients?</label>
		<item><label>Yes</label><value>yes</value></item>
		<item><label>No</label><value>no</value></item>
		</select1>





		<input relevant="/HMISFormA/internal/more3='yes'" bind="p4a"><label>Patient 4: Patient #</label></input>
		<input relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Name"><label>Patient 4: Name</label></input>
		<select1 relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Sex"><label>Patient 4: Sex</label>
			<item><label>Male</label><value>m</value></item>
			<item><label>Female</label><value>f</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more3='yes'" bind="p4b"><label>Patient 4: Age</label></input>
		<input relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Village"><label>Patient 4: Village</label></input>
		<input relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Parish"><label>Patient 4: Parish</label></input>
		<input relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Symptoms"><label>Patient 4: Symptoms and Signs</label></input>
		<input relevant="/HMISFormA/internal/more3='yes'" bind="p4c"><label>Patient 4: Date of Onset</label></input>
		<select1 relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Confirmed"><label>Patient 4: Clinically Confirmed?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Lab"><label>Patient 4: Lab Results Used in Diagnosis?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Immunisation"><label>Patient 4: Immunised?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
			<item><label>Unknown</label><value>u</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/Patients/Patient4/Status"><label>Patient 4: Status</label></input>

		<select1 relevant="/HMISFormA/internal/more3='yes'" ref="/HMISFormA/internal/more4"><label>More patients?</label>
		<item><label>Yes</label><value>yes</value></item>
		<item><label>No</label><value>no</value></item>
		</select1>





		<input relevant="/HMISFormA/internal/more4='yes'" bind="p5a"><label>Patient 5: Patient #</label></input>
		<input relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Name"><label>Patient 5: Name</label></input>
		<select1 relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Sex"><label>Patient 5: Sex</label>
			<item><label>Male</label><value>m</value></item>
			<item><label>Female</label><value>f</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more4='yes'" bind="p5b"><label>Patient 5: Age</label></input>
		<input relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Village"><label>Patient 5: Village</label></input>
		<input relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Parish"><label>Patient 5: Parish</label></input>
		<input relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Symptoms"><label>Patient 5: Symptoms and Signs</label></input>
		<input relevant="/HMISFormA/internal/more4='yes'" bind="p5c"><label>Patient 5: Date of Onset</label></input>
		<select1 relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Confirmed"><label>Patient 5: Clinically Confirmed?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Lab"><label>Patient 5: Lab Results Used in Diagnosis?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Immunisation"><label>Patient 5: Immunised?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
			<item><label>Unknown</label><value>u</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/Patients/Patient5/Status"><label>Patient 5: Status</label></input>

		<select1 relevant="/HMISFormA/internal/more4='yes'" ref="/HMISFormA/internal/more5"><label>More patients?</label>
		<item><label>Yes</label><value>yes</value></item>
		<item><label>No</label><value>no</value></item>
		</select1>





		<input relevant="/HMISFormA/internal/more5='yes'" bind="p6a"><label>Patient 6: Patient #</label></input>
		<input relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Name"><label>Patient 6: Name</label></input>
		<select1 relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Sex"><label>Patient 6: Sex</label>
			<item><label>Male</label><value>m</value></item>
			<item><label>Female</label><value>f</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more5='yes'" bind="p6b"><label>Patient 6: Age</label></input>
		<input relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Village"><label>Patient 6: Village</label></input>
		<input relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Parish"><label>Patient 6: Parish</label></input>
		<input relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Symptoms"><label>Patient 6: Symptoms and Signs</label></input>
		<input relevant="/HMISFormA/internal/more5='yes'" bind="p6c"><label>Patient 6: Date of Onset</label></input>
		<select1 relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Confirmed"><label>Patient 6: Clinically Confirmed?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Lab"><label>Patient 6: Lab Results Used in Diagnosis?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
		</select1>
		<select1 relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Immunisation"><label>Patient 6: Immunised?</label>
			<item><label>Yes</label><value>y</value></item>
			<item><label>No</label><value>n</value></item>
			<item><label>Unknown</label><value>u</value></item>
		</select1>
		<input relevant="/HMISFormA/internal/more5='yes'" ref="/HMISFormA/Patients/Patient6/Status"><label>Patient 6: Status</label></input>




		<input ref="/HMISFormA/ActionsTakenByHealthUnit">
			<label>Actions taken by the health unit</label>
		</input>
		<input ref="/HMISFormA/Remarks">
			<label>Remarks</label>
		</input>
		<input ref="/HMISFormA/NameOfInCharge">
			<label>Name of in-charge</label>
		</input>
</h:body>
</h:html>


